Mechanical Ventilation and Extracorporeal Membrane Oxygenation as a Bridging Strategy to Lung Transplantation: Significant Gains in Survival.

Mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO) are increasingly used to bridge patients to lung transplantation. We investigated the impact of using MV, with or without ECMO, before lung transplantation on survival after transplantation by performing a retrospective analysis of 826 patients who underwent transplantation at our high-volume center. Recipient characteristics and posttransplant outcomes were analyzed. Most lung transplant recipients (729 patients) did not require bridging; 194 of these patients were propensity matched with patients who were bridged using MV alone (48 patients) or MV and ECMO (49 patients). There was no difference in overall survival between the MV and MV+ECMO groups (p = 0.07). The MV+ECMO group had significantly higher survival conditioned on surviving to 1 year (median 1,811 days ([MV] vs. not reached ([MV+ECMO], p = 0.01). Recipients in the MV+ECMO group, however, were more likely to require ECMO after lung transplantation (16.7% MV vs. 57.1% MV+ECMO, p < 0.001). There were no differences in duration of postoperative MV, hospital stay, graft survival, or the incidence of acute rejection, renal failure, bleeding requiring reoperation, or airway complications. In this contemporary series, the combination of MV and ECMO was a viable bridging strategy to lung transplantation that led to acceptable patient outcomes.

Characteristics in response rates for surveys administered to surgery residents.

BACKGROUND: Surveys are important research tools that permit the accumulation of information from large samples that would otherwise be impractical to collect. Resident surveys have been used frequently to monitor the quality of postgraduate training. Low response rates threaten the utility of this research tool. The purpose of this study was to determine the standard response rate of surveys administered to surgery residents and identify characteristics associated with achieving greater response rates. METHODS: A search of peer-reviewed literature published between September 2003 and June 2011 was performed with the use of PubMed with Medical Subject Headings: "internship and residency," "surgery," "data collection," and "questionnaires." For inclusion, articles must have described a survey given to active surgery residents within the United States. Surveys were evaluated based on the following criteria: population size, response rate, incentive use, follow-up use, survey format (online vs paper), and institution versus national. RESULTS: Of 433 initial results, 47 met inclusion criteria with a mean response rate of 65.3%. Surveys administered in paper format had a greater response rate compared with those given electronically (mean 78.6% vs 36.4%, respectively, P < .001). Greatest mean response rates were seen for institutional surveys compared with those given nationally (83.1% vs 42% respectively, P < .001). CONCLUSION: Our review demonstrated that paper surveys administered at the institutional level and during assemblies integrated into residents' schedules demonstrated enhanced response rates. The validity and generalizability of data collected through such surveys will improve as the aspects which dictate response rate are better understood and implemented.

Central diabetes insipidus: a rare perioperative cause of severe hypernatraemia.

In this case report we describe the management of severe hypernatraemia following inadvertent water restriction. A 21-year-old woman with no reported medical history presented on transfer from an outside hospital with a complex volar upper extremity injury. Management both operatively and postoperatively involved a prolonged period of fasting which limited her access to drinking water Collateral history revealed that she had previously drunk copious amounts of water during the course of any given day and this had served to alleviate the dramatic symptoms of hypernatraemia that were rapidly manifest when her normal intake was curtailed. We outline the fluid management, administration of desmopressin and her subsequent recovery. A literature review of the management of central diabetes insipidus is also covered.

Incidence and prognostic influence of lymph node micrometastases in rectal cancer.

AIMS: The aim of this study was to determine the rate of lymph node micrometastases and evaluate their prognostic significance in rectal cancer. METHODS: Patients with either Dukes A or B rectal carcinoma who had undergone curative resection by either low anterior resection or abdominal perineal resection between 1991 and 2000 were selected from a prospectively collated database. None of the patients had metastasis at the time of surgery and none received adjuvant or neoadjuvant therapy. A single section from each lymph node was stained with haematoxylin and eosin (H+E) and with CAM 5.2 by immunohistochemistry. Statistical analyses were performed with Chi-square test. RESULTS: A total of 774 lymph nodes with a median of 14 lymph nodes per patient were examined, from a cohort of 56 patients with a median age of 66 years. In the 56 patients in whom lymph node metastases were not detected by haematoxylin-eosin staining, cytokeratin staining was positive in 15 lymph nodes from 10 patients. Nine patients had disease recurrence at a median follow-up of 98 months. The presence of lymph node micrometastases by immunohistochemistry did not predict either disease-free (p=0.44) or overall survival (p=0.63). CONCLUSION: Immunohistochemical staining detects micrometastases in rectal cancer which are not observed with H+E staining. However, no significant relationship was observed between disease relapse and rectal micrometastases detected by immunohistochemistry.

Thrombomodulin: tumour biology and prognostic implications.

BACKGROUND: Thrombomodulin (TM) is an endothelial receptor that exerts anti-coagulant, anti-fibrinolytic, and anti-inflammatory activity by inhibiting thrombin and cellular adhesion. There is growing evidence that TM plays a role in tumour behaviour. METHODS: The electronic literature (1966-2004) was reviewed with a specific focus on tumour biology. RESULTS: TM is expressed on both the endothelium and tumour cells in several cancers. Loss of expression denotes a more malignant profile with poorer prognosis. Loss of TM is mediated by hypoxia, endotoxin, and various cytokines, while up-regulation can be achieved by pharmacological manipulation (e.g. pentoxyfylline and statins). CONCLUSION: Originally described as an endothelial anticoagulant, TM plays a key role in tumour biology and prognostics, and provides a potential therapeutic target in impeding cancer spread.

Outcome of cadaveric renal transplantation in patients with psychiatric disorders.

Psychiatric illness has hitherto been considered a contraindication to solid organ transplantation in many centres. Reasons cited include a perceived lack of compliance with therapeutic drug regimes and the potential psychopharmacological interactions between psychotropic and immunosuppressant medication. We retrospectively examined the outcomes in 24 patients with psychiatric illnesses definable within the confines of the ICD 10 classification who underwent cadaveric renal transplantation between January 1990 and October 1999. The mean age was 31.5 +/- 17.1 years (range 9-68) at the time of transplantation. There were 13 male and 11 female patients. All received cyclosporine, azathioprine and steroid triple immunosuppressive therapy. The 1,3 and 5 year patient and graft survival was 87%, 82% and 65% respectively. The mean follow-up time was 43.67 +/- 38.11 months (range: 1 month-10 years 4 months). Compliance was excellent in all 24 cases. Seven patients died. The causes of graft loss were death with a functioning graft (n=3), vascular thrombosis (n=2), chronic rejection (n=2). The mean serum creatinine of the remaining 17 patients is 129 +/- 45.2mmol/l. Psychiatric illness, in itself, does not preclude the possibility of successful cadaveric renal transplantation.

Inspiratory flow limitation during sleep in pre-eclampsia: comparison with normal pregnant and nonpregnant women.

Self-reported snoring is common in pregnancy, particularly in females with pre-eclampsia. The prevalence of inspiratory flow limitation during sleep in preeclamptic females was objectively assessed and compared with normal pregnant and nonpregnant females. Fifteen females with pre-eclampsia were compared to 15 females from each of the three trimesters of pregnancy, as well as to 15 matched nonpregnant control females (total study population, 75 subjects). All subjects had overnight monitoring of respiration, oxygen saturation, and blood pressure (BP). No group had evidence of a clinically significant sleep apnoea syndrome, but patients with pre-eclampsia spent substantially more time (31+/-8.4% of sleep period time, mean+/-SD) with evidence of inspiratory flow limitation compared to 15.5+/-2.3% in third trimester subjects and <5% in the other three groups (p=0.001). In the majority of preeclamptics, the pattern of flow limitation was of prolonged episodes lasting several minutes without associated oxygen desaturation. As expected, systolic and diastolic BPs were significantly higher in the pre-eclamptic group (p<0.001), but all groups showed a significant fall (p< or =0.05) in BP during sleep. Inspiratory flow limitation is common during sleep in patients with pre-eclampsia, which may have implications for the pathophysiology and treatment of this disorder.

Experience with methicillin resistant Staphylococcus aureus at the Nairobi Hospital.

The problem of MRSA was recognised in mid year of 1996 among both in and out patients at the Nairobi Hospital. The Infection Control Committee, through the microbiology section of the laboratory, immediately accelerated the surveillance programme which included culturing all the wards, beddings, sinks, utensils, furniture and staff. The source was identified and disinfectant methods were modified to eradicate the infection from the community. Relentless fight against the micro-organism through the recommended methods resulted in no more cases at the end of the year. Nosocomial infections must be recognised by all hospitals which must have viable infection control programmes. The Nairobi hospital has an active and on-going infection control programme which enabled this problem to be identified and solved in a timely manner.